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Hospital-based stewardship does not reduce fluoroquinolone prescribing at discharge
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Hospital-based antibiotic stewardship programs are associated with a reduction in fluoroquinolone prescribing while patients are hospitalized, but not when they are discharged, according to findings from a retrospective cohort study.
“First and foremost, we found that antibiotic stewardship works. Pre-prescription approval and prospective audit and feedback reduced fluoroquinolone prescribing. But stewardship doesn’t work where you don’t look,” Valerie M. Vaughn, MD, MSc, assistant professor of medicine and research scientist in the division of hospital medicine at Michigan Medicine and the Ann Arbor VA Medical Center, told Infectious Disease News.
“The majority of fluoroquinolone prescribing happens at discharge, and programs weren’t monitoring these prescriptions. As a result, fluoroquinolone use at discharge didn’t improve.”
Vaughn and colleagues conducted the study between December 2015 and September 2017 in 48 hospitals participating in the Michigan Hospital Medicine Safety Consortium. They included general care, medical patients hospitalized with pneumonia or with a positive urine culture for a urinary tract infection. The researchers assessed each hospital’s fluoroquinolone stewardship efforts and compared fluoroquinolone exposure — ciprofloxacin, levofloxacin and moxifloxacin use — between hospitals with and without fluoroquinolone stewardship programs.
Of the 11,748 patients included in the study, 6,820 had pneumonia and 4,928 had a positive urine culture. According to the study, 29.2% of hospitals reported implementing fluoroquinolone stewardship interventions, including pre-prescription approval or prospective audit and feedback, or both.
Stewardship was associated with fewer patients receiving a fluoroquinolone, with 37.1% (95% CI, 30.3%-43.9%) of patients at hospitals with fluoroquinolone stewardship receiving fluoroquinolone prescriptions compared with 48.2% (95% CI, 44.4%-51.9%) of patients at hospitals without fluoroquinolone stewardship programs. Moreover, stewardship was associated with fewer fluroquinolone treatment days per 1,000 patients — 2,282 (95% CI, 1,799–2,765) vs. 3,096 (95% CI, 2,818–3,374; P = .01). Vaughn and colleagues noted that this decline was driven by lower inpatient prescribing.
However, they reported that 66.6% of fluoroquinolone treatment days occurred after discharge. At hospitals that implemented stewardship interventions, twice as many new fluoroquinolone prescriptions were reported after discharge compared with hospitals without stewardship. Specifically, hospitals with fluoroquinolone stewardship had a 15.6% prescribing rate for new fluoroquinolone prescriptions after discharge compared with 8.4% at hospitals without stewardship.
“Given the frequency of fluoroquinolone prescribing after discharge, hospital-based stewardship programs should implement ‘discharge stewardship,’ including adding recommendations for discharge prescribing in institutional guidelines, educating providers on those guidelines, and tracking and monitoring adherence to those guidelines,” Vaughn said.
She said clinicians should be “mindful” of what is being prescribed not only in the hospital but at discharge as well because high-risk antibiotics can expose patients to potential harm.
“Which antibiotic to prescribe at discharge should be an active thought, not an afterthought,” Vaughn said. – by Marley Ghizzone
Disclosures: The authors report no relevant financial disclosures.
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